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BMJ：你发现这张普通膝关节平片中暗藏的典型标志了吗？-案例报道

2016-11-24 haofan MedSci原创

前交叉韧带断裂
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膝部外伤患者，尤其是当病人描述出现外旋外翻运动时，在膝关节侧位片上应注意寻找股骨外侧切迹征。股骨外侧切迹征往往提示膝关节前外侧旋转不稳定以及需要进行MRI检查来评估软组织损伤程度。

一名健康的23岁足球运动员在左膝盖创伤后几个小时入院。跑步的时候，患者不得不通过转动右脚来保持左脚不动（外旋外翻应力）。患者没有听到也没感觉到爆裂声或咔嚓声，但随后左脚无法承重，并直接出现肿胀和内侧局部疼痛。X线结果如下（图1）。


图1 左膝侧位片 

问题：X片上有什么异常表现，这种表现可能与哪种疾病有关？ 

答案：股骨外侧切迹或沟征（红线）所示，这是提示存在前交叉韧带断裂（图2）。

图2 左膝侧位片出现股骨外侧髁凹陷（红线）。

讨论

侧位平片显示股骨外侧切迹出现过深的异常凹陷（图2）。这种典型的中外侧股骨髁软骨凹陷是因胫骨平台后外侧受到外部强力所致。在文献中对（前交叉韧带断裂）引起的凹陷深度有两种定义，Cobby等人使用1.5毫米作为（判断前交叉韧带断裂）凹陷深度截断值，它比正常值高出了3倍标准差；Warren等人的结论是凹陷深度至少2毫米以上才提示为前交叉韧带撕裂。股骨外侧切迹征与前交叉韧带撕裂之间的相关性只在0%-26%的患者中被发现，这与判断前交叉韧带断裂的凹陷深度所采用的定义、人群和损伤机制有关。根据来自于124例前交叉韧带撕裂患者其中4名（凹陷＞2毫米）患者的影像学结果，Yu等人发现其诊断前交叉韧带完全撕裂的敏感性为3.2%，特异性为100%。Gentili等人通过对89例研究对象（54例前交叉韧带撕裂患者和35例前交叉韧带正常者）进行磁共振检查以凹陷深度>1.5毫米作为诊断标准，研究者发现其诊断前交叉韧带撕裂的敏感性为19%，特异性为100%。在MRI结果中，根据位置和深度，Grimberg等人发现其诊断的敏感性可达49%～66%，特异性可达70%～89%。因此，股骨外侧切迹征的出现提示前交叉韧带撕裂，但无股骨外侧切迹征并不能排除前交叉韧带疾病。MRI结果可证实前交叉韧带的撕裂，并连同半月板后角撕裂，内侧副韧带1级扭伤和股骨外侧髁和胫骨近端广泛的骨髓水肿。

学习点

膝部外伤患者，尤其是当患者描述出现外旋外翻运动时，在膝关节侧位片上应注意寻找股骨外侧切迹征。股骨外侧切迹征往往提示膝关节前外侧旋转不稳定以及需要进行MRI检查来评估软组织损伤程度。 

原始出处： 

Paul T P W Burgers, et al. A typical sign on a plain knee radiograph. BMJ.23 November 2016.

本文系梅斯医学（MedSci）原创编译整理，转载需授权！

评论区 (4)
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  1. [GetPortalCommentsPageByObjectIdResponse(id=1848164, encodeId=0aee184816434, content=<a href='/topic/show?id=2977356edc' target=_blank style='color:#2F92EE;'>#BMJ#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3567, encryptionId=2977356edc, topicName=BMJ)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=148754, createdName=gaoxiaoe, createdTime=Mon Mar 20 17:04:00 CST 2017, time=2017-03-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=163293, encodeId=4828163293be, content=文章不错，值得学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Fri Dec 16 14:04:01 CST 2016, time=2016-12-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=158573, encodeId=84751585e3fe, content=x片协助诊断，MRI才是硬道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dd161986667, createdName=玉笏三郎, createdTime=Sun Nov 27 21:44:46 CST 2016, time=2016-11-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=158472, encodeId=026b1584e2f4, content=嗯，很有用！, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20161126/IMG58399D3E1C1C97201.jpg, createdBy=2e8e1986648, createdName=飘过心头, createdTime=Sun Nov 27 11:09:23 CST 2016, time=2016-11-27, status=1, ipAttribution=)]
    2017-03-20 gaoxiaoe

    #BMJ#

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1848164, encodeId=0aee184816434, content=<a href='/topic/show?id=2977356edc' target=_blank style='color:#2F92EE;'>#BMJ#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3567, encryptionId=2977356edc, topicName=BMJ)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=148754, createdName=gaoxiaoe, createdTime=Mon Mar 20 17:04:00 CST 2017, time=2017-03-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=163293, encodeId=4828163293be, content=文章不错，值得学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Fri Dec 16 14:04:01 CST 2016, time=2016-12-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=158573, encodeId=84751585e3fe, content=x片协助诊断，MRI才是硬道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dd161986667, createdName=玉笏三郎, createdTime=Sun Nov 27 21:44:46 CST 2016, time=2016-11-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=158472, encodeId=026b1584e2f4, content=嗯，很有用！, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20161126/IMG58399D3E1C1C97201.jpg, createdBy=2e8e1986648, createdName=飘过心头, createdTime=Sun Nov 27 11:09:23 CST 2016, time=2016-11-27, status=1, ipAttribution=)]
    2016-12-16 1e10c84am36(暂无匿称)

    文章不错，值得学习

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1848164, encodeId=0aee184816434, content=<a href='/topic/show?id=2977356edc' target=_blank style='color:#2F92EE;'>#BMJ#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3567, encryptionId=2977356edc, topicName=BMJ)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=148754, createdName=gaoxiaoe, createdTime=Mon Mar 20 17:04:00 CST 2017, time=2017-03-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=163293, encodeId=4828163293be, content=文章不错，值得学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Fri Dec 16 14:04:01 CST 2016, time=2016-12-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=158573, encodeId=84751585e3fe, content=x片协助诊断，MRI才是硬道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dd161986667, createdName=玉笏三郎, createdTime=Sun Nov 27 21:44:46 CST 2016, time=2016-11-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=158472, encodeId=026b1584e2f4, content=嗯，很有用！, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20161126/IMG58399D3E1C1C97201.jpg, createdBy=2e8e1986648, createdName=飘过心头, createdTime=Sun Nov 27 11:09:23 CST 2016, time=2016-11-27, status=1, ipAttribution=)]
    2016-11-27 玉笏三郎

    x片协助诊断，MRI才是硬道理

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1848164, encodeId=0aee184816434, content=<a href='/topic/show?id=2977356edc' target=_blank style='color:#2F92EE;'>#BMJ#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3567, encryptionId=2977356edc, topicName=BMJ)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=148754, createdName=gaoxiaoe, createdTime=Mon Mar 20 17:04:00 CST 2017, time=2017-03-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=163293, encodeId=4828163293be, content=文章不错，值得学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Fri Dec 16 14:04:01 CST 2016, time=2016-12-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=158573, encodeId=84751585e3fe, content=x片协助诊断，MRI才是硬道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dd161986667, createdName=玉笏三郎, createdTime=Sun Nov 27 21:44:46 CST 2016, time=2016-11-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=158472, encodeId=026b1584e2f4, content=嗯，很有用！, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20161126/IMG58399D3E1C1C97201.jpg, createdBy=2e8e1986648, createdName=飘过心头, createdTime=Sun Nov 27 11:09:23 CST 2016, time=2016-11-27, status=1, ipAttribution=)]
    2016-11-27 飘过心头

    嗯，很有用！

    0